Sever’s Disease in Children

What is Sever’s Disease?

Sever’s disease is a condition where the growth plate at the back of the heel bone becomes inflamed in growing children. Also known as Calcaneal Apophysitis, Sever’s is a temporary disorder that occurs in children, primarily when they are experiencing a growth spurt. It is one of the most common causes of heel pain in growing children. The name “Sever’s disease” is misleading because it is not a disease in the traditional sense; it is mechanically induced rather than resulting from a pathological condition.

What symptoms may my child have with Sever’s Disease?

The following are some of the most typical symptoms associated with Sever’s Disease:

• Heel pain during physical exercise, especially activities that require running or jumping.
• Heel pain tends to be worse after exercise or sports.
• Usually, children with Sever’s have a tendency to limp, particularly during or after physical activity.
• There is not typically any visible erythema or swelling.
• Sever’s may occur in one or both heels.

What are the causes of heel pain in children?

As previously discussed, Sever’s occurs in children during a period where they are experiencing a growth spurt. The following are factors which can make children more prone to developing Sever’s Disease:

• Children who engage in frequent physical and sporting activities especially those involving repetitive running and jumping are at higher risk of developing Sever’s Disease.
• Tightness of the Achilles tendon.
• Weak ankle dorsiflexion can play a role.
• Frequent running on hard surfaces.
• Obesity in children is a risk factor for Sever’s.
• Biomechanical factors such as genu varum (bowlegs) and pes planus (flat feet), among others, play a role in the progression of Sever’s Disease.
• Worn-out footwear or footwear with poor cushioning.
• Sever’s most often occurs between the ages of 8 and 14 years old.

Diagnosis

Diagnosis of Sever’s disease will partly be determined based on your child’s symptoms. The doctor or physiotherapist will likely also do a test called a Squeeze test where they will apply pressure to both sides of the heel to see whether this triggers a pain-response. On assessment, there will usually be decreased range of motion for passive dorsiflexion of the ankle, and this may also cause pain. During the examination, the healthcare professional may have your child stand on tip toes, as this also provokes reproduction of symptoms of Sever’s.

X-rays are generally not used to diagnose Sever’s disease but may be used to rule out other possible conditions such as a fracture. A diagnostic ultrasound, a radiation-free imaging method, may be done to rule out possibility of Achilles tendinopathy or bursitis.

How can I help my child to recover?

Sever’s Disease doesn’t tend to cause long term effects, however while it is present it can be very physically limiting for your child. Treatment focuses around decreasing your child’s activity levels. Affected children will have to stop physical activity that causes pain until symptoms settle.

• Stretching and mobility of the ankle, particularly flexibility of the calf muscle is important in the recovery of Sever’s Disease
• It is worth investing in a good pair of shoes with plenty of cushioning for your child. Alternatively, heel pads or cushioned orthotics may be used.

An assessment with a physiotherapist will help to determine whether any biomechanical abnormalities may be a factor and how this can be helped. The physiotherapist will give your child a programme of stretches and exercises to follow based on their findings. They may also consider taping your child’s foot as this has been shown to reduce pain caused by Sever’s.

• To ensure that your child stays active, exercises like swimming, cycling, or other low-impact activities can replace high-impact sports involving running and jumping until the pain subsides.

How long will it take for Sever’s Disease to resolve?

With appropriate management, symptoms of Sever’s disease typically resolve within a few weeks to two months.

Citations

1. Smith JM, Varacallo M. Sever Disease. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021
2. McSweeney SC, Reed L, Wearing S. Foot Mobility Magnitude and Stiffness in Children With and Without Calcaneal Apophysitis. Foot Ankle Int. 2018 May;39(5):585-590.
3. James AM, Williams CM, Luscombe M, Hunter R, Haines TP. Factors Associated with Pain Severity in Children with Calcaneal Apophysitis (Sever Disease). J Pediatr [Internet]. 2015;167(2):455–9.
4. Ramponi DR, Baker C. Sever’s Disease (Calcaneal Apophysitis). Adv Emerg Nurs J. 2019;41 (1):10-4.
5. Elengard T, Karlsson J, Silbernagel KG. Aspects of treatment for posterior heel pain in young athletes. Open access journal of sports medicine. 2010;1:223.
6. Launay F. Sports-related overuse injuries in children. Orthopaedics & Traumatology: Surgery & Research. 2015 Feb 1;101 (1):S139-47